The provision of the baby box was associated with safe sleep practices in a low-resource community: a randomized control trial in Ecuador

Hartley Feld, Janeth Ceballos Osorio, Marisol Bahamonde, Thomas Young, Pablo Boada, Mary Kay Rayens

Research output: Contribution to journalArticlepeer-review


Background: Sudden Unexpected Infant Deaths (SUID) can occur between 1 month and 1 year of age and are inequitably distributed with a greater burden in populations with numerous health disparities. Modifying the infant sleep environment to promote safe sleep is the most effective risk reduction strategy to reduce SUID. The provision of baby boxes with a mattress and infant supplies has been part of a larger anti-poverty social justice maternity package for decades in Finland. While infant mortality rates have generally improved after the maternity package was introduced, little is known about whether the provision of the baby box increased safe sleep practices. The purpose of the study was to evaluate whether the provision of a Finnish-style baby box reinforced safe infant sleep practice in the home in a low-resource community in Ecuador. Methods: In this longitudinal randomized controlled trial all participants received the same safe sleep education in their third trimester of pregnancy (n = 100). This was followed by randomization into two groups; the control received a diaper bag and newborn gifts, and the intervention group received a baby box and the same gifts at each timepoint. Four infant sleep practices (room sharing, bed sharing/co-sleeping, position, and soft items in the sleep environment) were assessed at 1 month and 1 months post-delivery during a home visit where safe sleep education was also reinforced with both groups. Results: Those in the baby box group were 2.5 times more likely to report safe sleep practices compared with mothers in the diaper bag group at 1 month (odds ratio [OR] = 2.45 and 95% confidence interval [CI]: 1.03–5.86; χ2 = 4.1, p =.043). The group difference was also present at 6-months post-birth: those in the baby box group were 2.9 times more likely to report safe sleep practices compared with those in the diaper bag group (OR = 2.86 and 95% CI: 1.16–7.05; χ2 = 5.2, p =.022). Conclusions: While not all participants used the box regularly, the mothers who received the box were more likely to practice safe sleep at 1 month and 6 months. This suggests the baby box may have served as an important prompt towards safer infant sleep practice. Trial registration: (Clinical Trial Registry, per not applicable under 42 CFR 11.22(b) as the study Facility Location was not in the United States (took place in Ecuador), does not involve FDA IND or IDE, and does not involve a drug, biological or device product that is manufactured in and exported from the US for study in another country. The University of San Francisco Quito, Research Ethics Committee in Human Beings approved the study, #2017- 127 M. The University of Kentucky Office of Research Integrity also approved the study, IRB # 42965).

Original languageEnglish
Article number31
JournalBMC Pediatrics
Issue number1
StatePublished - Dec 2023

Bibliographical note

Funding Information:
We would like to acknowledge Shoulder to Shoulder Global at the University of Kentucky, the Fundación Hombro a Hombro, and our clinical and community partners at Centro de Salud Hombro a Hombro in Santo Domingo, Ecuador. Research was performed in accordance with the Declaration of Helsinki which included obtaining informed consent to participate and all adult participants were 16 years of age or older.

Funding Information:
This study was funded by a small grant from the Children’s Miracle Network administered by the University of Kentucky, Department of Pediatrics. The Network did not play a role in the study. We would also like to acknowledge that this project utilized RedCap as a data collection tool and this was supported by the National Institute of Health (NIH) National Center for Advancing Translational Sciences through grant number UL1TR001998. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

Publisher Copyright:
© 2023, The Author(s).


  • Infant sleep environment, Baby box, SUID prevention, Ecuador

ASJC Scopus subject areas

  • Pediatrics, Perinatology, and Child Health


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